Evidence-based VR simulation training of temporal bone surgery

The Visible Ear Simulator has been systematically evaluated and altogether there is considerable evidence for using the Visible Ear Simulator as an educational platform for temporal bone surgical training. On this page we have gathered a list of the >30 peer-reviewed publications investigating training in the Visible Ear Simulator and related topics by our group and teams at other institutions.

Learning curves

Studies investigating the learning curves and retention of performance:

  • Andersen SA, Konge L, Cayé-Thomasen P, Sørensen MS. Learning curves of virtual mastoidectomy in distributed and massed practice. JAMA Otolaryngol Head Neck Surg. 2015; 141(10):913–918. https://doi.org/10.1001/jamaoto.2015.1563
  • Andersen SA, Konge L, Cayé-Thomasen P, Sølvsten Sørensen M. Retention of mastoidectomy skills after virtual reality simulation training. JAMA Otolaryngol Head Neck Surg. 2016 Jul 1; 142(7):635–40. https://doi.org/10.1001/jamaoto.2016.0454
  • Andersen SA, Konge L, Mikkelsen PT, Cayé-Thomasen P, Sørensen MS. Mapping the plateau of novices in virtual reality simulation training of mastoidectomy. Laryngoscope. 2017 Apr;127(4):907–914. https://doi.org/10.1002/lary.26000
  • Fartoussi HA, Sørensen MS, Andersen SAW. Learning Curves in Directed Self-Regulated Virtual Reality Training of Mastoidectomy and the Role of Repetition and Motivation. J Int Adv Otol. 2023 Mar;19(2):99-104. https://doi.org/10.5152/iao.2023.22753


Studies investigating the transfer from VR simulation training to dissection performance:

  • Andersen SA, Foghsgaard S, Konge L, Cayé-Thomasen P, Sørensen MS. The effect of self-directed virtual reality simulation on dissection training performance in mastoidectomy. Laryngoscope. 2016 Aug; 126(8):1883–8. https://doi.org/10.1002/lary.25710
  • Andersen SA, Cayé-Thomasen P, Sørensen MS. Novices perform better in virtual reality simulation than in traditional cadaveric dissection training of mastoidectomy. Journal of Surgical Simulation. 2015; 2:68–75. https://doi.org/10.1102/2051-7726.2015.0014

Assessment and metrics

Studies investigating assessment and metrics-based assessment:

  • Andersen SA, Cayé-Thomasen P, Sølvsten Sørensen M. Mastoidectomy Performance Assessment of Virtual Simulation Training Using Final-Product Analysis. Laryngoscope. 2015 Feb; 125(2):431–5. https://doi.org/10.1002/lary.24838
  • West N, Konge L, Cayé-Thomasen P, Sørensen MS, Andersen SA. Peak and ceiling effects in final-product analysis of mastoidectomy performance. J Laryngol Otol. 2015 Nov; 129(11):1091–6. https://doi.org/10.1017/S0022215115002364
  • Al-Shahrestani F, Sørensen MS, Andersen SA. Performance metrics in mastoidectomy training: A systematic review. Eur Arch Otorhinolaryngol. 2019 Mar;276(3):657-664. https://doi.org/10.1007/s00405-018-05265-9
  • Andersen SA, Mikkelsen PT, Sørensen MS. Expert sampling of VR simulator metrics for automated assessment of mastoidectomy performance. Laryngoscope. 2019 Sep;129(9):2170–2177. https://doi.org/10.1002/lary.27798
  • Andersen SAW, Park YS, Sørensen MS, Konge L. Reliable Assessment of Surgical Technical Skills Is Dependent on Context: An Exploration of Different Variables Using Generalizability Theory. Acad Med. 2020 Dec;95(12):1929-1936. https://doi.org/10.1097/ACM.0000000000003550

Decentralized and distributed training

Studies investigating the use of the Visible Ear Simulator for distributed and decentralized training:

  • Andersen SA, Fogshgaard S, Cayé-Thomasen P, Sørensen MS. The effect of a distributed virtual reality simulation training program on dissection mastoidectomy performance. Otol Neurotol. 2018 Dec; 39(10):1277-1284. https://doi.org/10.1097/MAO.0000000000002031
  • Frendø M, Thinggaard E, Konge L, Sørensen MS, Andersen SA. Decentralized Virtual Reality Mastoidectomy Simulation Training: A Prospective, Mixed-Methods Study. Eur Arch Otorhinolaryngol. 2019 Oct;276(10):2783–2789. https://doi.org/10.1007/s00405-019-05572-9
  • Frendø M, Cayé-Thomasen P, Konge L, Sørensen MS, Andersen SA. Decentralized Virtual Reality Training of Mastoidectomy Improves Cadaver Dissection Performance: A Prospective, Controlled Cohort Study. Otol Neurotol. 2020 Apr;41(4):476-481. https://doi.org/10.1097/MAO.0000000000002541

Cognitive load

Studies on cognitive load (learning theory) in relation to temporal bone surgical training:

  • Andersen SA, Mikkelsen PT, Konge L, Cayé-Thomasen P, Sørensen MS. Cognitive load in mastoidectomy skills training: virtual reality simulation and traditional dissection compared. J Surg Educ. 2016 Jan-Feb; 73(1):45–50. https://doi.org/10.1016/j.jsurg.2015.09.010
  • Andersen SA, Konge L, Cayé-Thomasen P, Sørensen MS. Cognitive load in distributed and massed practice in virtual reality mastoidectomy simulation. Laryngoscope. 2016 Feb; 126(2):E74–9. 10. https://doi.org/10.1002/lary.25449
  • Andersen SA, Konge L, Sørensen MS. The effect of distributed virtual reality simulation training on cognitive load during subsequent dissection training. Med Teach. 2018; 40(7):684–698. https://doi.org/10.1080/0142159X.2018.1465182
  • Andersen SA, Mikkelsen PT, Konge L, Cayé-Thomasen P, Sørensen MS. The effect of implementing cognitive load theory based design principles in virtual reality simulation of surgical skills. Advances in Simulation. 2016; 1:20. https://doi.org/10.1186/s41077-016-0022-1
  • Rasmussen SR, Konge L, Mikkelsen PT, Sørensen MS, Andersen SA. Notes from the Field: Secondary Task Precision for Cognitive Load Estimation during Virtual Reality Surgical Simulation Training. Eval Health Prof. 2016 Mar; 39(1):114–20. https://doi.org/10.1177/0163278715597962

Learning supports

Studies of the use of learning supports in the Visible Ear Simulator:

  • Andersen SA, Guldager M, Mikkelsen PT, Sørensen MS. The effect of structured self-assessment in virtual reality simulation training of mastoidectomy. Eur Arch Otorhinolaryngol. 2019 Dec;276(12), 3345–3352. https://doi.org/10.1007/s00405-019-05648-6
  • Andersen SA, Mikkelsen PT, Sørensen MS. The effect of simulator-integrated tutoring for guidance in virtual reality simulation training. Simul Healthc. 2020 Jun;15(3):147-153. https://doi.org/10.1097/SIH.0000000000000414
  • Andersen SA, Frendø M, Guldager M, Sørensen MS. Understanding the effects of structured self-assessment in directed, self-regulated simulation-based training of mastoidectomy: a mixed methods study. J Otol. 2020 Dec;15(4):117-123. https://doi.org/10.1016/j.joto.2019.12.003
  • Andersen SAW, Frithioff A, von Buchwald JH, Sørensen MS, Frendø M. Am I doing this right? Structured self-assessment during simulation training of mastoidectomy improves cadaver dissection performance: a prospective educational study. Eur Arch Otorhinolaryngol. 2023 Jan;280(1):97-103. https://doi.org/10.1007/s00405-022-07454-z
  • Frithioff A, Frendø M, von Buchwald JH, Trier Mikkelsen P, Sølvsten Sørensen M, Arild Wuyts Andersen S. Automated summative feedback improves performance and retention in simulation training of mastoidectomy: a randomised controlled trial. J Laryngol Otol. 2022;136(1):29-36. https://doi.org/10.1017/S0022215121003352

Visualization and case variability

  • Frithioff A, Frendø M, Mikkelsen PT, Sørensen MS, Andersen SA. Ultra-high-fidelity virtual reality mastoidectomy simulation training—a randomized, controlled trial. Eur Arch Otorhinolaryngol. 2020 May;277(5):1335-1341. http://dx.doi.org/10.1007/s00405-020-05858-3
  • Arnesen KA, Frithioff A, Sørensen MS, Andersen SAW, Frendø M. Mastoidectomy Training: Is Anatomical Variation Needed? A Randomized, Controlled Trial on Performance and Skills Transfer From Virtual Reality to a Three-Dimensional Printed Model. Otol Neurotol. 2022 Sep 1;43(8):900-907. https://doi.org/10.1097/MAO.0000000000003607
  • Sieber DM, Andersen SAW, Sørensen MS, Mikkelsen PT. OpenEar Image Data Enables Case Variation in High Fidelity Virtual Reality Ear Surgery. Otol Neurotol. 2021 Sep 1;42(8):1245-1252. https://doi.org/10.1097/MAO.0000000000003175

Cochlear implantation simulation

  • Frendø M, Frithioff A, Konge L, Cayé-Thomasen P, Sørensen MS, Wuyts Andersen SA. Cochlear Implant Surgery: Virtual Reality Simulation Training and Transfer of Skills to Cadaver Dissection-A Randomized, Controlled Trial. J Int Adv Otol. 2022 May;18(3):219-224. https://doi.org/10.5152/iao.2022.21429
  • Frithioff A, Frendø M, Mikkelsen PT, Sørensen MS, Andersen SAW. Cochlear implantation: Exploring the effects of 3D stereovision in a digital microscope for virtual reality simulation training – A randomized controlled trial. Cochlear Implants Int. 2022 Mar;23(2):80-86. https://doi.org/10.1080/14670100.2021.1997026
  • Frendø M, Frithioff A, Konge L, Sørensen MS, Andersen SAW. Cochlear implant surgery: Learning curve in virtual reality simulation training and transfer of skills to a 3D-printed temporal bone – A prospective trial. Cochlear Implants Int. 2021 Nov;22(6):330-337. https://doi.org/10.1080/14670100.2021.1940629
  • Frendø M, Frithioff A, Konge L, Foghsgaard S, Mikkelsen PT, Sørensen MS, Cayé-Thomasen P, Andersen SAW. Assessing competence in cochlear implant surgery using the newly developed Cochlear Implant Surgery Assessment Tool. Eur Arch Otorhinolaryngol. 2022 Jan;279(1):127-136. https://doi.org/10.1007/s00405-021-06632-9

Evaluations by other research groups

The Visible Ear Simulator has been evaluated by other research groups:

  • Fang T-Y, Wang P-C, Liu C-H, Su M-C, Yeh S-C. Evaluation of a haptics-based virtual reality temporal bone simulator for anatomy and surgery training. Computer Methods and Programs in Biomedicine. 2014;113(2):674-681. http://dx.doi.org/10.1016/j.cmpb.2013.11.005
  • Bennett WO, Wilmot VV, Reddy VM, Alderson DJ. The realism and usefulness of the Voxel-Man TempoSurg and the Visible Ear simulator. RCS Bulletin. 2015;97(2):66-69. http://dx.doi.org/10.1308/147363515X14134529300148
  • Adebayo A, Khalil H, Prior M. Construct validity of the Visible Ear Simulator: a surgical teaching tool for temporal bone dissection in abstracts presented at the Otology Section Meetings, Royal Society of Medicine, Matthew Yung Short Paper Prize, 6 March 2015, London, UK. J Laryngol Otol. 2015;130(10):E5–1. http://dx.doi.org/10.1017/S0022215115002807


PhD thesis on using the Visible Ear Simulator for mastoidectomy training of novices:

PhD thesis on VR simulation training of cochlear implantation in the Visible Ear Simulator:

  • Frendø M: Virtual Reality simulation-based training of cochlear implant surgery: perspectives of performance, assessment, and transfer. University of Copenhagen, April 2021. https://otonet.dk/Frendo_thesis.pdf

Research doctoral thesis (for degree of DMSc) on VR simulation-based training and assessment including cognitive load perspectives:

  • Andersen SA. Simulation-based training and assessment of mastoidectomy —perspectives on the outside, inside, and in-between conditions of practice. University of Copenhagen, August 2023. https://doi.org/10.5281/zenodo.8265247

European questionnaire study mapping the current status of temporal bone surgical training:

Book chapter on simulation-based training in otology and temporal bone surgery

Data and development

The Visible Ear Simulator is based on high-resolution digital photographs of cryo-sections of a fresh-frozen human temporal bone resulting in unprecedented quality of the main virtual model:

  • Sorensen MS, Dobrzeniecki AB, Larsen P, Frisch T, Sporring J, Darvann TA. The visible ear: a digital image library of the temporal bone. ORL J Otorhinolaryngol Relat Spec. 2002;64(6):378-381. http://dx.doi.org/10.1159/000066089
  • Sieber D, Erfurt P, John S, et al. The OpenEar library of 3D models of the human temporal bone based on computed tomography and micro-slicing. Sci Data. 2019;6:180297. http://dx.doi.org/10.1038/sdata.2018.297

The Visible Ear dataset has also been used to develop educational 3D models and for virtual exploration of the temporal bone anatomy:

  • Kahrs LA, Labadie RF. Freely-Available, True-Color Volume Rendering Software and Cryohistology Data Sets for Virtual Exploration of the Temporal Bone Anatomy. J Mol Microbiol Biotechnol. 2013;75(1):46-53. http://dx.doi.org/10.1159/000347083
  • Wang H, Merchant SN, Sorensen MS. A Downloadable Three-Dimensional Virtual Model of the Visible Ear. J Mol Microbiol Biotechnol. 2007;69(2):63-67. http://dx.doi.org/10.1159/000097369

The technical development of the simulator is detailed in the following publications: